01. a. heinemann - special register in germany.ppt. a. heine… · group (see note) 18 poisoning by...
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Special Register in Germany: Overdose including prescription opioids and new developments in the reporting system
Dr. A. HeinemannInstitute of Legal Medicine
University Medical Center Hamburg-Eppendorf , Germany
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German SR
� German SR in charge of Federal Criminal Police Office (Bundeskriminalamt)
� 16 regional Land Offices of Criminal Investigation report to SR (aggregated data)
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DRD longterm series: Germany GMR (Destatis)/ SMR (BKA):
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DRD longterm series: Germany GMR (Destatis)/ SMR (BKA):
-20%
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Opiate purity and availability
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German Bundesländer:Drug- related deaths per 100.000 inhabitants (2011)
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Germany (SMR): DRD, detection of opiates in monodrug/polydrug overdoses (%)
550
603571
529
279
357 346 359326
290
2007 2008 2009 2010 2011
monovalent heroin/morphine polydrug heroine/morphine
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4,7 4,5 4,5 4,8
8,3
11,712,5
13,9
11,6
24,3
0,6 0,8 0,6 0,61,5
0,0
5,0
10,0
15,0
20,0
25,0
30,0
2007 2008 2009 2010 2011
mono methadone (%)
poly methadone involved (%)
buprenorphine involved (%)
Germany (SMR): DRD/Overdose, detection of prescription opiates (%)
%
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49,2
13,3
31,4
1,3
26,6
7,6
13,7
39,3
15,6
10,40,0
4,4
8,0
7,5
21,1
23,7
Bavaria
Baden-Wuerttemberg
Saxony-Anhalt
Thuringia
Hamburg
Bremen
Northrhine-Westfalia
Lower Saxony
Hesse
Rhineland- PalatinaSaarland
Saxony
Berlin
Mecklenburg-West.Pomerania
Schleswig-Holstein
Brandenburg
Methadoneinvolved in OD (%) (mean 2007-2011)
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2,9
0,0
0,0
0,0
0,7
0,3
0,0
0,4
0,0
0,00,0
0,0
0,0
0,0
2,4
0,6
Bavaria
Baden-Wuerttemberg
Saxony-Anhalt
Thuringia
Hamburg
Bremen
Northrhine-Westfalia
Lower Saxony
Hesse
Rhineland- PalatinaSaarland
Saxony
Berlin
Mecklenburg-West.Pomerania
Schleswig-Holstein
Brandenburg
Buprenorphine involved in OD (%) (mean 2007-2011)
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Berlin: Methadone detection rate at OD
46 45
35 37 50
140135 133
99
75
0
20
40
60
80
100
120
140
160
2007 2008 2009 2010 2011
with methadone involved (n)
OD (N)
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Hamburg
21
13
20 20
26
46
38
44
36
40
0
5
10
15
20
25
30
35
40
45
50
2007 2008 2009 2010 2011
with methadone involved (n)
DRD (n)
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Northrhine- Westfalia
0
50
100
150
200
250
300
350
2007 2008 2009 2010 2011
with methadone involved
(n)
Overdose (n)
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Bavaria
0
50
100
150
200
250
300
2007 2008 2009 2010 2011
with methadone involved
(n)
OD (n)
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Regional analysis across German Bundesländer: OST and methadone detection rate at OD
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Regional analysis across German Bundesländer: OST and methadone detection rate at OD
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Regional analysis across German Bundesländer: OST and methadone detection rate at OD
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82,0
68,5
66,2
30,8
56,0
32,4
92,8
98,8
77,0
94,670,4
83,6
94,6
100,0
47,2
90,2
Bavaria
Baden-Wuerttemberg
Saxony-Anhalt
Thuringia
Hamburg
Bremen
Northrhine-Westfalia
Lower Saxony
Hesse
Rhineland- PalatinaSaarland
Saxony
Berlin
Mecklenburg-West.Pomerania
Schleswig-Holstein
Brandenburg
Autopsy rate in DRD (%) (mean 2007-2011)
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Quality of data in SMR
30,8 32,4
47,2
64,2
82
90,2
98,8
65,7 67,4
40,8
56,5
7,1
44,3
10,9
1,3
7,6
21,1 20,1
49,2
10,9
39,3
0
20
40
60
80
100
120
Autopsy rate
Monovalent heroin (% of OD)
Methadone detected (% of OD)
%
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Fentanyl- related deaths (SMR, personal comm.)
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Fentanyl- related overdose in Bavaria (Data from Bavarian SMR, 2011/2012)
8%
6%
20%
2%38%
26%Fentanyl only
Fentanyl + alcohol
Fentanyl + psychoactivemedicines
Fentanyl + psychoactivemedicines +alcohol
Fentanyl + opiates/cocaine
Fentanyl +methamphetamine/others
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Substances detected in some cases of polydrug overdose in Berlin and Hamburg in 2011
� Oxycodone/Oxymorphone
� Palladone/Hydromorphone
� Fentanyl
� Mephedrone/Methoxymethcathedrone (MMC)
� Methylendioxypyrovalerone (MDPV)
� Ketamine/Ketanest
� Pseudoephedrine
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Quality of reporting: Traditional report structure of German SMR
Poisoining due to Number
Heroine
Polydrug pois. With heroine involved
Cocaine
Polydrug pois. With cocaine involved
Amphetamine
Polydrug pois. With amphetamine
MDMA
MDMA polydrug
Prescription opioids
- methadone/polamidon
- Subutex/buprenorphine
Prescription opiods in polydrug pois.
- with methadone/polamidone
- with Subutex/buprenorphine
Other illicit drugs/ unknown drug
Suicide
Disease due to Longterm harm of drug use
Accident/ Other manners
Absolute number *
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Traditional report structure of German SR
Poisoining due to
Heroine
Polydrug pois. With heroine involved
Cocaine
Polydrug pois. With cocaine involved
Amphetamine
Polydrug pois. With amphetamine
MDMA
MDMA polydrug
Prescription opioids
- methadone/polamidon
- Subutex/buprenorphine
Prescription opiods in polydrug pois.
- with methadone/polamidone
- with Subutex/buprenorphine
Other illicit drugs/ unknown drug
Suicide
Disease due to Longterm harm of drug use
Accident/ Other manners
Absolute number *
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Traditional report structure of German SR
Poisoining due to
Heroine
Polydrug pois. With heroine involved
Cocaine
Polydrug pois. With cocaine involved
Amphetamine
Polydrug pois. With amphetamine
MDMA
MDMA polydrug
Prescription opioids
- methadone/polamidon
- Subutex/buprenorphine
Prescription opiods in polydrug pois.
- with methadone/polamidone
- with Subutex/buprenorphine
Other illicit drugs/ unknown drug
Suicide
Disease due to Longterm harm of drug use
Accident/ Other manners
Absolute number *
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Traditional report structure of German SR
Poisoining due to
Heroine
Polydrug pois. With heroine involved
Cocaine
Polydrug pois. With cocaine involved
Amphetamine
Polydrug pois. With amphetamine
MDMA
MDMA polydrug
Prescription opioids
- methadone/polamidon
- Subutex/buprenorphine
Prescription opiods in polydrug pois.
- with methadone/polamidone
- with Subutex/buprenorphine
Other illicit drugs/ unknown drug
Suicide
Disease due to Longterm harm of drug use
Accident/ Other manners
Absolute number *
Includes again poisoinings
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Traditional report structure of German SR
Poisoining due to
Heroine
Polydrug pois. With heroine involved
Cocaine
Polydrug pois. With cocaine involved
Amphetamine
Polydrug pois. With amphetamine
MDMA
MDMA polydrug
Prescription opioids
- methadone/polamidon
- Subutex/buprenorphine
Prescription opiods in polydrug pois.
- with methadone/polamidone
- with Subutex/buprenorphine
Other illicit drugs/ unknown drug
Suicide
Disease due to Longterm harm of drug use
Accident/ Other manners
Absolute number * ???
Include also poisoinings
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Hindrances
� Absolute numbers of overdoses are not conclusive
� Absolute numbers of indirect drug- related deaths categories were not conclusive
� Share of confirmed substance detections (by autopsy/toxicology) was unknown
� Comparability between German GMR and SR fails
� EMCDDA Standard not applicable
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Table 4: Coding of values for the variables "Cause" and "Filter_D"
CausePoisoning Filter_D Broad
group(see note)
18 Poisoning by opioids only (excluding methadone) 1 O
19 Poisoning by methadone only 1 O
20 Poisoning by poly-substances including opioids 1 O
21 Poisoning by (poly)substances excluding opioids 1 NO
22 Poisoning by psychoactive medicines 0 -
23 Poisoning by unspecified/unknown substances 1 NS
Cause Other than poisoning# Filter_D
24 Natural/internal causes 0 -
25 Accidents other than by poisoning 0 -
26 Suicide other than by poisoning 0 -
27 Homicide other than by poisoning 0 -
28 Undetermined causes other than by poisoning 0 -
# These other causes are also mutually exclusive. One case may only be coded to one cause category.
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Table 4: Coding of values for the variables "Cause" and "Filter_D"
CausePoisoning Filter_D Broad
group(see note)
18 Poisoning by opioids only (excluding methadone) 1 O
19 Poisoning by methadone only 1 O
20 Poisoning by poly-substances including opioids 1 O
21 Poisoning by (poly)substances excluding opioids 1 NO
22 Poisoning by psychoactive medicines 0 -
23 Poisoning by unspecified/unknown substances 1 NS
Cause Other than poisoning# Filter_D
24 Natural/internal causes 0 -
25 Accidents other than by poisoning 0 -
26 Suicide other than by poisoning 0 -
27 Homicide other than by poisoning 0 -
28 Undetermined causes other than by poisoning 0 -
# These other causes are also mutually exclusive. One case may only be coded to one cause category.
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Issues to be solved
� Define Categories which are mutually exclusive� Monodrug Opiate poisoinings should be reported separately (so
far only given for heroine/ methadone/ buprenorphine )� Avoid multiple nomination in Polydrug poisonings with / without
opioides� Monodrug poisoings with „psychoactive medicine“ should be
separated� „Other illicit drugs“ should exclude opioides� „Other illicit drugs detected“/ unknown substance should be
separated� Separation of suicidal or accidental poisonings from non-
poisoning suicides and accidents. � Separation of disease due to longterm harm of drug use from
poisoings: Separate mixed category when both are relevant in a case
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No Category
Bundesland
(n)
Cases withautopsy/toxxicology (n)
A Poisoning by opioids/ opiates
A.1Monodrug poisoing: Heroin/Morphine
A.2Monodrug poisoing: prescription opiate
A.2.1 subgroup : methadone
A.2.2 subgroup buprenorphine
A.2.3 subgroup other prescription opioids (to be listed)
B
Mixed Poisoning including opioids/ opiates (e.g.
amphetamines,cocaine/crack, cannabis, hallucinogens, solvants, synthetic drugs, Sedatives, alkohol, others. Includes poisoingswith suicidal intent
B.1
Polydrug poisoning including Heroin/Morphine ("Substanzen"
nach Definition unter B)
B.2Polydrug poisoning including prescription opiates
B.2.1 subgroup : methadone
B.2.2 subgroup buprenorphine
B.2.3 subgroup other prescription opioids (to be listed)
New reporting structure in German SR (1)
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New reporting structure in German SR (2)
Bundesland
(n)
Cases withautopsy/toxicology (n)
C Poisoning excluding opioids/ opiates
C.1 Monodrug poisoning: Cocaine/crack
C.2 Monodrug poisoning: Amphetamines
C.3 Monodrug poisoning: MDMA, MDE, MDA
C.4 Polydrug poisoning including cocaine/crack (without opiates)
C.5 Polydrug poisoning including amphetamines (without opiates)
C.6Polydrug poisoning including MDMA/MDE/MDA (without opiates)
DPolydrug poisoing including stimulants and opiates (subgroup of B)
D.1 Polydrug poisoning including cocaine/crack (with opiates)
D.2 Polydrug poisoning including amphetamines (with opiates)
D.3 Polydrug poisoning including MDMA/MDE/MDA (with opiates)
E Poisonings by psychoactive medicines without illicit drugs
FNot specified substances in poisonings (but illicit drugs suspected)
Poisonings: Others/ not assignable (to be listed)
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New reporting structure in German SR (3)
Bundesland (n)
Cases with
autopsy/toxxicology (n)
G Suicides
G.1Suicide by poisoning
G.2Suicide by other means than poisoning
H Disease due to longterm harm by drug use
H.1
Subgroup: Mixed cause of death: Longterm harm
combined with poisoning.
I Accident (non- poisoning accidents)
J Other/ not assignable (only non- poisoning cases)
Total drug- related deaths(sum up mutually exclusive
categories =A+B+C+E+G2+H+I+J) 0 0
Autopsy rate : Total (%)
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